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SAN �O-UIN COUNTY ENVIRONMENTAL HEALTH •ARTMENT <br /> DATE 1[(;7—657 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> / l n p SITE MITIGATION& LOP <br /> SHADED AREAS FOR END USE ONLY OWNERIDN 01000/�/.'7O UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CRECRIFOwNFRIS CNRREN YONFREw1TH EHO <br /> PROPERTYOWNERNAME <br /> FRSs MI- LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OmERHome ADDRESS n -I <br /> Cm 7V-a- <br /> ST TE „ LP ^ � <br /> OWNER MAILING ADDRESS <br /> MAIUNGADDRESSCnY \� STATE ZIP \\ <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP YSZVERNMENTAGERICY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ <br /> FACILITY ID# INv# AccouNrlDPR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB-!( OTSC_EPA <br /> �q-oo�11 4p �R 3888 lG4 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION/,BUT A NEW SCOPE OF WORK? 1 YES ❑ No ❑ 1L <br /> SUSINEss1FAauJTY/SnvA'ROIECT NAME (2 4F ��T1•�- r ,SS �A ` <br /> SrrEA00REBS/PROJECTI.00ATION /I l� Vv � V^��r� h 1 �^< 2-E-3 _1•12��SUITS# BUSINMPHHONE <br /> Cm 'V_OII/ I V L W CA- L�� -7 G;, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE �� KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILm ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS Cm STATE ZIP <br /> SIC CODE APN 53- 22 <br /> COMMENT: <br /> 11 <br /> J (Ick- <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME � rl� ` ATTENTION:ORCARE OF(OPTIONAL)Toe- :?' \ <br /> MAILINGADDRESS �k-1/` PHONE 3��`_j\�^, <br /> Cm � STATE LP <br /> -(� UY <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND COMPLIARCE ACI 01'LEUGaIENT: 1,the undersigned Applicanq certify that I am the Owner,Operator,AuthorizedAgenq to,Responsible Pony and I acknowledge that all PERAf!TF£ES, <br /> PENALTIES,EA•FascC EAT C",mc and/or HOURLY CRARGES associated with fids project will be billed to me a/the address identified above as the ACCOLM ADDRESS for this Site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQuu;COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws mad REGDLATIONS. As the undersigned Owner,Operator,Audmri ed Agent,or Responsible Per1v for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and Other environmental assessment information to SAN JOAQUIN COUNTY ENWRO I'll DEPART¢M as seen as it is available <br /> and at the same time it is provided to me or my representative. <br /> ��//�'� <br /> APPLICANT NAME(PLEASE PRINT) l:/j ( P;.-(, V�� SIGNATURE <br /> f <br /> TDLE C C S—� TAXID# <br /> APPROATDBY L� DATE AC,..ND OFFICE PROCESSING COMPIETED BY DATE <br /> SITE MITIGATION AMOUNT PAID CAT OF PAYMENT PAYMENT TYPE RECEIPT# CHECK/# c R/E��CEIVED:sBnY WORK PLAN PE <br /> FEES J�S -/� Cf'/l� "_/(¢l� W(NAJ,6R 1ILO <br />